HomeMy WebLinkAboutPP25-171 BUILDING DEPARXMENT DEC 5 2025
VILI,AGE OF RYE#00OK
938 KING, ET RYE BILK,NY 10573
Y%dokny.gov
PLUMBING PERMIT APPLICATION --fir 1
FOR OFFICE USE ONLY BP,*.- PP#: /
Approval Date: Permit Fee: $ L` A
Approval Signature: Disapproved:
v (furs are nun-rerundable)
DO NOT START N1 'ORK or CONSTRt CTION t \Ill.A PERMIT HAS BEEN ISSUED RY THE BUILDING
INSPECTOR.THE ADMINISTRATI% E FEE FOR of ORK PROGRESSED OR COMPLETED WITHOUT A
PERMIT IS 12%OF THE TOTAL.(COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of
a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this
document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes.
1.Address: S 1 14V`L SBL: Zone
2.Proposed Work: �:04Ulf-.4— S'f'OLe— &2 r l l r•, ,�n l 4�'",`,tf` -rYO r+7 !''"04nL%f—
3.Property Owner: 014 5T f ollp - p Address:
Phone#:-'?1PL qq / Cell#: Z yZ-j t Zi email:
4.Master Plumber: Address: I I 812414,k— AL-Y—/ i�6 /UY
Lic.#:LS 2 I Phone#: Q`Y-S =(�/(S Cell#: �!r'J� f ly _email ' l:`�lv"(�' �•
Company Name: RZPllfl Address: !
INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLONN71NG SCHEDULE:
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other; Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
I st Floor L
2nd Floor
Yd Floor
411 Floor
5'Floor
Exterior
&* List Other EquipmenVProvide Details:
(Notarized Signatures Required Next 2 Pages)
.i. 6r112024
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
being,duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing as the applicant)
and further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application..
That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use
conducted at the above captioned property will be in conformance with the details as set forth and contained in this application
and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire
Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations.
Sworn IQ before me this Sworn t before me is
day of 20 day of 20
21—�ature of PropErty Owner Signature of Applicant
Print Name oT Propert Print Name of Ap.l'
A GALLO
t NOTARY MBUC,ST OF NEW YORK
A60'MI DONNA GALLO
in Dutchcss Canty NOTARY PUBLIC,STATE OF NEW YORK
Ca omliiidw>�May 17,20 � Rc&kitiom No.01 GA6024891
Quali5ed in ihrtchem Canty
This application must be properly completed in its entirety and must 17p 20 of
the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications
not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be
returned to the applicant.
-2-
6nno2a
BUILD.INP-Di ARTMENT
VILL} 'E OF RYE fIROOK
938 KING � EET RYE BROOIC,NV 10573
(9t4)939-0668
w rN w.r�a brook n).gov
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED
ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT
APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT .
STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as:
3, J�tQ C3 , residing at, / J A.c,- +� d i n e
(E'F III 1;.;_.
being duly sworn,deposes and states that(s)he is the applicant above named, and further states that(s)he is the
legal owner of the pro erty to which this Affidavit of Compliance pertains at;
✓ n c �'' LZ
Z L , Rye Brook, NY.
Further that all statements contained herein are true,and that to the best of his/her knowledge and belief,that
there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further
that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources
of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State,
County and Village Codes.
, c,et E'n+pertti (?��nerfsll
-
i
Sworn t before me this DUlYNAGJ�.i�O
day of , 20 5 N0TARY NMJC,STATE OF NEW YORK
QeaiW to DUkh=Casty
C®mac E*=Mq 17,20
611/2024
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